MillenniumVillagesProject:ChildCount+:ACommunityHealthEventsReportingandAlerts SystemAConceptPaper

"Tomakepeoplecount,wefirstneedtobeabletocountpeople."DrLEEJongwook,FormerDirector GeneralWHO(20042006) A. Background Reducingchildandmaternalmortality,by66%and75%respectively,havebeenidentifiedascore MillenniumDevelopmentGoal(MDG)targets.InmuchofsubSaharanAfrica,10to20percentof childrendiebeforeturningfive,andthedeathofmothersduringchildbirth,arareeventinindustrialized countries,occursfartoofrequently. Thereissubstantialevidencedocumentingthepositiveeffectsofarangeofsimpleandcosteffective interventionsonmaternalandchildsurvivalincludingvaccinations,oralrehydrationtherapy, insecticidetreatedbednetsalongsidestrengtheninghealthsystemstoimproveantenatalcare,safe deliveryandtheintegratedmanagementofsickchildren[14].However,theirwidescaleapplicationin areasoftheworldthatneeditmostremainsinsufficient. InthesubSaharanAfricancontext,numerouschallengeshamperprogresstowardsrapidgainsin maternalchildsurvival.First,weakanddeeplyunderfinancedhealthsystemshavebeenunableto introduceandsustainthedeliveryofcriticalinterventions[4].Second,factorssuchuserfees,distance, andtransportcreatesignificantaccessbarriers.Itisestimatedthatovera100millionpeoplefallinto povertyeachyearduetoofoutofpockethealthexpenses[5].Finally,thelimitedavailabilityof accurateandtimelyhealthinformationhasmadeitdifficulttotracktheprogressofinterventionsand identifycoveragegaps[6]. TheMillenniumVillagesProject(MVP)seekstoaddresstheselimitations.MVPinvolvesthecoordinated deliveryofapackageofprovenhealthanddevelopmentinterventionsatthevillagelevelamong14 diversesitesin10subSaharanAfricancountries[7].Theaimoftheprojectistorapidlyaccelerate progresstowardstheMDGtargetsovera5to10yearperiod.Inthehealthsector,MVPemphasizes integrateddeliveryoffreeminimumpackageofmaternalnewbornchildhealthservices,withgoalof achievinguniversalcoveragethroughinputstoreferralhospitalsandprimarycareclinics,alongside providingdirectsupporttohouseholdsthroughacadreofpaidprofessionalcommunityhealthworkers. CHWsareanimportantlinkbetweenthehealthsectorandthecommunity[8],andthereissubstantial evidencesuggestingtheycanbeeffectivevehiclesforreducingmaternalandchildmortalityand improvinghealthoutcomes[3,9,10].ArandomizedtrialintheGambiademonstrateda61%reduction 1

inneonatalmortalityaftertraditionalbirthattendantsweretrained[11].Othermorerecentcluster randomizedtrials[2,1214]andcontrolledtrials[1517]havealsodocumentedpronouncedbenefitsof CHWprogramsonreducingneonatal,perinatalandmaternalmortality. IntheMVPcontext,CHWsaresalariedsecondaryschoolgraduatesgenerallyfromthelocalcommunity whoaretrainedinaminimumsetofcorecompetencies.Therearenearly800CHWsacrossthe14MV sites.Dependingongeographyandpopulationdensity,thereisaratioofapproximately1CHWfor every100200households,witheachhouseholdisvisitedatleastonaquarterlybasis.Bytakinghealth carefromtheclinicsdirectlytovulnerablehouseholds,theprojecthopestodemonstrateimprovements indiseasepreventionaswellasintheearlydetection,treatmentandreferralofsickindividuals. WhileCHWscanplayacriticalroleinfacilitatingcoveragewithlifesavinginterventions,theyalsohave thepotentialtoprovidethevitalfeedbackofhouseholdlevelhealthinformation.Aspartoftheir householdscreeningvisits,CHWshavethepotentialtogenerateahostofprogramrelevantinformation including:theregistrationofcommunityhealtheventsincludingrecentbirthsanddeaths;theburdenof illnesssuchasacutemalnutritionormalaria;andlevelsofcoveragewithessentialinterventionssuchas immunizations,antenatalcareandskilleddelivery. Thiscollectionofhouseholdlevelinformationcanbegreatlyfacilitatedbynewadvancesinmobile communicationstechnology.WithineachMVsite,eachCHWisprovidedwithacellphone.Througha partnershipwithEricsson,nearlyallMillenniumVillageshaveachievedhighlevelsofcellphone coverage.TheMVPhasbeenpilotingtheuseofelectronicmobilephonebasedsystemsforthe collectionofhealthrelatedinformationinanumberofsites.Forexample,inSauri,Kenyathe ChildCountSystemhasallowedover90%ofchildrenunder5yearsofagetobeelectronically registeredandroutinelymonitoredthroughanSMS(textmessage)basedreportingandmonitoring systemfornutrition,immunization,malaria,andothersignsofchildhoodillness(See www.ChildCount.org). ThewidespreaduseofCHWstofacilitatingthisrealtimecollectionofhouseholdleveldatainremote ruralAfricansettingshasnotbeenpreviouslyattempted.Thisproposaloutlinesanovelapplicationof themobiletechnologytoguidethetargetingofpublichealthinterventions.Thecentralaimofthe proposedMVPCommunityHealthEventsRegistryandAlert(CHILDCOUNT+)Systemistofacilitate reductionsinchildandmaternaldeathsaswellasearlydetection,referral,andtreatmentfortargetrisk signs. Theobjectivesareasfollows: 1. Todevelopandimplementacommunityhealtheventsreportingandverbalautopsysystemfor CHWs 2. Todevelopandimplementtwowaymobilephonebasedcommunityhealtheventsreporting, feedback,andillnessalertsystemtomonitorandmanagefollowupforbirthsanddeaths; pregnantwomenandnewborns;childrenunder5years;andadultillnessessuchasHIV,TB, malaria,andotherchronicnoncommunicablediseases. 2

3. Todeveloptoolsandreportingformatsandstructurestobetterenabletheuseofdataforactive casemanagementanddecisionmakingaswellasperformancemonitoringofhealthworkers Potentialoutputsofthisworkincludeascalablemodelforthedeliveryandmonitoringofhousehold leveldeliveryofcriticalmaternalnewbornchildhealthinterventionsthatisappropriateandrelevantto regionsoftheworldwhereeffectivestrategiestoaddresshealthrelatedMDGsareurgentlyrequired. B. Descriptionofprojectobjectives 1. Todevelopandimplementacommunityhealtheventsreportingandverbalautopsysystem forCHWs 2. Todevelopandimplementtwowaymobilephonebasedcommunityhealtheventsreporting, feedback,andillnessalertsystemtomonitorandmanagefollowupforbirthsanddeaths; pregnantwomenandnewborns;childrenunder5years;andadultillnessessuchasTB, malariaandnoncommunicablediseases Communityhealtheventsmonitoring,whichwouldincludeaVerbalAutopsysystemforallmaternal childdeaths,hasbeenputforthasakeystrategytoaddresstheinformationinterventionnexuswithin theMillenniumVillagesProject.Thehypothesisisthattimelyinformationontheburdenofdisease alongsidebetterunderstandingpatternsofpreventablemortalityandchallengesfacedinaccessingcare hasthepotentialtocriticallyinformthetargetinganddeliveryofinterventions.Bybuildingupon existingsitepersonnelandresources,alowcostMVPCHILDCOUNT+Systemisbeingdevelopedtotest thishypothesis.Theproposedsystemhasanumberofdifferentcomponentswhichwillbeoutlined brieflybelow. i) CommunityHealthWorkers(CHWs)andCHWCoordinators:InallMVPsites,CHWshavebeen introducedtomaximizethedeliveryofhealthinformationandservicestohouseholdsinthe projectclusters.Therecurrentlyaratioof1CHWtoevery100200households,withhousehold visitstakingplaceatleastquarterly.CHWsaresupportedbytheCHWCoordinatorwhoisinturn supportedbyHealthCoordinators(doctorsoralliedhealthprofessionals),andprovidea spectrumofhealthinterventionstotargethouseholds. o TheCHWCoordinatorwillberesponsibleforoverallintegrationofthepaperbasedand electronicsystemintotheCHWProgramineachsiteaswellasusingthedatagenerated toimproveoutreachactivitiesinthecommunities. TheCHWswillberesponsiblefordatacaptureandfollowupatthehouseholdlevel.As partofitsoverallHealthServicesDeliverySystemsandMonitoringandEvaluation,the MillenniumVillagesProjectisfurtherdevelopingthefunctionalityandexpanding ChildCount(seewww.childcount.or)beyondchildrenunder5.ChildCount+:A CommunityHealthEventsReportingandAlertSystemwillintegratewithexisting 3

informationmanagementsystemsandcatalyzeactionaroundthefollowingcommunity healthevents: BirthsandDeaths Under5ChildHealthEvents:newbornchecks,nutritionalStatus,presenceof diarrhea,immunizationsandthepresenceofdangersigns[MDG4] Pregnancyrelatedeventsincludingantenatalcarevisitsandinstitutional deliveries[MDG5] PresenceofHIV,TB,malaria[MDG6]aswellasotherchronicconditions ii) Mobilephonebasedhealthinformationsystem:AllCHWsinaclusterwillhaveaccesstoa mobilephonebasedcommunicationsystemforthereportingofcommunityhealthevents.This platformwillallowreportingofeventsthroughSMS(RapidSMS)orstructuredquestionnaire (JavaRosa)byaCHWtobetransmittedinstantlytoacentralizeddatabase(MGVNet),whichwill thenthroughanalgorithmdrivensystemprovidefeedbackand/orguidanceonappropriate actiontobetakenwhethertotreat/monitorinthehome,refertoafacility,and/oractivatethe emergencytollfreenumber.ThissystemwillbelinkedbyclientIDtothefacilitybased electronicmedicalrecordsystemnamelyOpenMRS,sothatallcommunityenteredinformation willbeavailabletocareproviders.Whileallsiteswillinitiallybeginwithpaperbaseddata collection,itistheintentiontoimplementthiscomponentasquicklyaspossibleacrossallsites. eHealthSpecialists,DatabaseManagers,andaroamingteamoftechnicalsupportproviderswill bestrategicallyengagedanddeployedbasedontheneedsandconditionsofeachsite. iii) OpenMRSandUniqueIDsystem:Itisimportanttobeabletouniquelyidentifypersonswithin theMillenniumVillagesaswellasthosewhoattendMVPclinicsorotherwiseuseMVPservices. Uptonow,theonlyuniqueidentifierswerethoseusedbytheresearchvillageswhichwerenot availableforpublicuse.AspartoftheChildCount+andMGVNetsystems,OpenMRSwill generateaunique6digitalphanumericIDwhichcanbeusedthroughoutthevillages.Itwas designedtobeshortenoughtobeenteredusingamobilephone,yetproduceenoughunique numberstocovertheentireMVPclusterineachsite.OpenMRSwillalsobeusedastheprimary databaseforcollectingallfacilitybased,personspecificdatainthecluster,allowingfor continuityofinformationfromthecommunityallthewayuptothedistricthealthofficeandthe MinistryofHealth. iv) Verbalautopsyspecialist:WhenadeathisalertedthroughtheChildCount+system,theVA specialist,anonclinicalhealthworkerspeciallytrainedintheVAmethodology,willbedeployed toconductaverbalautopsyatthehouseholdleveltocollectinformationonthebasiccauseof death.Dependingsitecapacity,VAswilleitherbeconductedbyasingleVASpecialistoraby SeniorCHWs(thereisoneSeniorCHWforevery5juniorCHWs).ItisanticipatedthatVAswill visithouseholdswithin26weeksafteradeathhastakenplace.StandardizedVAshavebeen 4

developedforuseatallMVPsites,withseparateformsforadults/maternaldeathsandfor children.ThesemodifiedVAs(paperbaseddatacapture)havetwomaincomponents: o MedicalCauseofdeath:thishasbeenderivedfromVAtoolsthathavebeenpreviously validatedtoassesssignsandsymptomsexperiencedbythedeceasedinthetime precedingdeath.Themoduleconsistsofbothcloseandopenendedsectionsasper bestpracticeguidelines. Socialautopsy:aspecificmodulehasbeendevelopedfortheMVPsites,andincluded detailsregardingthesocialcircumstancessurroundingdeath.Itincludesinformationon healthseekingbehavior,accessbarrierstohealthcare,communication,transport,and economics.

AllVAformswillbeenteredintoacomputerizeddatabasemonthly,andsubjecttoanalgorithmic assessmentofthemedicalcauseofdeathaswellassocialcircumstancessurroundingthedeath.The medialcauseofdeathalgorithmsareestablished,validtechniquesfordeterminingtheprobablecause ofdeathandcanbeeasilyadaptedorappendedforlocalcontext.Thisinnovationeliminatestheneed fordualphysicianbasedassessments,whichcanbebothexpensiveandcreatealongtimedelayin generatingrealtimeinformationforprogrammanagers. 3. Todeveloptoolsandreportingformatsandstructurestobetterenabletheuseofdatafor activecasemanagementanddecisionmakingaswellasperformancemonitoringofhealth workers Thebroadaimofthissystemistoimprovethequalityofcare,andoptimizethetargetinganddeliveryof essentialhealthservices.TheChildCount+systemwillprovidethebasisforlongitudinalinformation trackingatanindividualandhouseholdlevelwithintheMillenniumVillages.Integratedwithanexisting platformknownastheMillenniumGlobalVillageNetwork(MGVNet),ChildCount+willtakeadvantage ofthemultilingual,multinational,opensourceinformationsystembeingimplementedthroughoutMVP. Capturinginformationviapaper,mobilephonesandcomputerswillbringtogetherinformationfrom community,clinicandreferralcenterstoprovideanoverarchingviewofhealthwithinthevillages. Threekeycomponentswillallowthisinformationtobeusedtoinformdecisionmaking.Theseinclude analertsystemforcriticalevents;thedevelopmentofaplatformforquarterlyreportingofaggregate indicators,and;aprocessofusingthemtoinformservicedeliveryknownasCommunityMorbidityand MortalityRounds. i) Alertsystem:Aseachindividualhasauniqueidentificationnumber,thesystemhasthecapacity to facilitate alerts which are text messages sent to CHWs to help target service delivery. For example,thesemightsignaltheneedforfollowupofaseverelymalnourishedchild,thataclinic patienthasalabvaluethatrequiresareturnvisittotheclinic,orthatarecentlydeliveryhas taken place and a neonatal check is required. This will be an addition to logbooks that have beendevelopedtofacilitatehouseholdandpatientbasedtracking. 5

 ii) CommunityBasedReportingandAggregateIndicators:Itiscriticalthatinformationcollectedin the community is available to local decisionmakers to facilitate planning and service delivery. Toachievethisgoal,reportingandvisualizationtoolswillbeprovidedaspartoftheChildCount+ andMGVNetimplementation.UsingbasicreportingtoolssuchasMSExcelandPivottables,in addition to standard reports, the system will allow local users with appropriate privileges to view important information at the touch of a button. In addition, standard performance indicators that are reported to MVP on a quarterly basis will be automatically calculated for entryintothewebbasedcentralizeddatasystem. iii) CommunityMorbidity&MortalityRounds:theprincipleintentoftheVAmodulewithinMVP ChildCount+systemistogenerateinformationonthecauseandsocialcircumstances surroundingtreatmentdelaysanddeathtoinformandimprovethedeliveryofhealthand developmentinterventionsontheground.Monitoringinformationaswellasdatacollectedon causeofdeathwillbecompiledandformthebasisofacommunitymorbidityandmortality roundswhichwillbecoordinatedbetweentheMVPHealthCoordinators,CHWCoordinators, clinicstaff,VAS,andtheCHWs.Thesemeetingswillprovideaforumforengagingwiththe medicalandsocialautopsydatawithappropriaterecommendationsbeingmaderegardingthe introductionsofnewhealthprograms,modificationsinthedeliveryortargetingofexisting healthprograms,ortheneedtoliaisewithothersectorssuchasinfrastructure,educationor nutritiontoaddressotherremediableconcerns. C. References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Black,R.E.,S.S.Morris,andJ.Bryce,Whereandwhyare10millionchildrendyingeveryyear? Lancet,2003.361(9376):p.22262234. Bhutta,Z.A.,etal.,Interventionstoaddressmaternal,newborn,andchildsurvival:whatdiff erencecanintegratedprimaryhealthcarestrategiesmake?TheLancet,2008.372:p.972989. Bhutta,Z.A.,etal.,CommunityBasedInterventionsforImprovingPerinatalandNeonatalHealth OutcomesinDevelopingCountries:AReviewoftheEvidence.Pediatrics,2005.115:p.519617. Ekman,B.,I.Pathmanathan,andJ.Liljestrand,Integratinghealthinterventionsforwomen, newbornbabies,andchildren:aframeworkforaction.TheLancet,2008.372:p.9901000. Xu,K.,etal.,ProtectinghouseholdsfromCatastrophichealthexpenditures.HealthAffairs,2007. 6:p.972983. Hill,K.,Makingdeathscount.BulletinoftheWorldHealthOrganization,2006.84(3):p.162. Sachs,J.D.andJ.W.McArthur,TheMillenniumProject:aplanformeetingtheMillennium DevelopmentGoals.TheLancet,2005.365(347353). UNICEF,StateoftheWorld'sChildren:ChildSurvival.2008,UNICEF:NewYork. Haines,A.,etal.,Achievingchildsurvivalgoals:potentialcontributionofcommunityhealth workers.TheLancet,2007.369:p.21212131. Bhutta,S.Z.andS.Soofi,Communitybasednewborncare:arewethereyet?TheLancet,2008. 372:p.11241126. Greenwood,A.,etal.,EvaluationofaprimaryhealthcareprogrammeinTheGambia.I.The impactoftrainedtraditionalbirthattendantsontheoutcomeofpregnancy.JournalofTropical MedicineandHygiene,1990.93:p.5866. 6

12. 13. 14. 15. 16. 17.

Kumar,V.,etal.,Effectofcommunitybasedbehaviourchangemanagementonneonatal mortalityinShivgarh,UttarPradesh,India:aclusterrandomisedcontrolledtrial.TheLancet, 2008.372. Baqui,A.H.,etal.,Improvingnewbornsurvivalandchanginghouseholdessentialnewborncare practicesinruralBangladesh:theProjahnmoexperience.TheLancet,2008.371:p.19361944. Jokhio,A.H.,H.R.Winter,andK.K.Cheng,Aninterventioninvolvingtraditionalbirthattendants andperinatalandmaternalmortalityinPakistan.NewEnglandJournalofMedicine,2005.352: p.20912099. Bhutta,Z.A.,etal.,Implementingcommunitybasedperinatalcare:resultsfromapilotstudyin ruralPakistan.BulletinoftheWorldHealthOrganization,2008.86:p.452459. Bang,A.T.,etal.,Effectofhomebasedneonatalcareandmanagementofsepsisonneonatal mortality:fieldtrialinruralIndia.TheLancet,1999.354:p.19551961. Kohn,D.,CommunityinvolvementsavesnewbornsinIndia.TheLancet,2008.371:p.12351236.